Small-area variation in child under-vaccination in India: a multilevel analysis of cross-sectional data from 36 states and Union Territories, 707 districts, and 22,349 small-area clusters

Mira Johri; Sunil Rajpal; Rockli Kim; S V Subramanian

doi:10.1016/j.lansea.2024.100504

Small-area variation in child under-vaccination in India: a multilevel analysis of cross-sectional data from 36 states and Union Territories, 707 districts, and 22,349 small-area clusters

Lancet Reg Health Southeast Asia. 2024 Nov 8:32:100504. doi: 10.1016/j.lansea.2024.100504. eCollection 2025 Jan.

Authors

Mira Johri^{1

2}, Sunil Rajpal³, Rockli Kim^{4

5}, S V Subramanian^{6

7}

Affiliations

¹ Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.
² Département de gestion, d'évaluation, et de politique de santé, École de Santé Publique (ESPUM), Université de Montréal, Montréal, Québec, Canada.
³ Department of Economics, FLAME University, Pune, India.
⁴ Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, South Korea.
⁵ Division of Health Policy and Management, College of Health Science, Korea University, Seoul, South Korea.
⁶ Harvard Center for Population & Development Studies, Cambridge, MA, USA.
⁷ Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Abstract

Background: India has made exceptional advances in child immunisation, but subnational inequities in vaccination coverage impede attainment of key programmatic goals. Our study provides an up-to-date national portrait of local variations in child vaccination using a comprehensive set of indicators relevant to routine immunisation.

Methods: Indicators representing unvaccinated (zero-dose) children, incomplete basic immunisation, and vulnerability to measles and polio, were constructed from India's 2019-2021 National Family Health Survey. We used four-level random effects logistic regression models to partition the total outcome variation over state, district and cluster levels, and produce precision-weighted estimates of prevalence across clusters. District-level prevalence and within-district variation using standard deviation measures were derived for each outcome. Boxplots graphically summarised the distribution of precision-weighted mean cluster prevalence by state.

Findings: The analysis included 87,622 children aged 12-36 months. Clusters accounted for 67.6% (var: 1.36; SE: 0.127) of the variation among zero-dose children, and more than 50% for all indicators. Districts with a higher prevalence of under-vaccination tended to have higher within-district heterogeneity, interpretable as greater within-district child vaccination inequities. For vaccines administered in the first year of life, the northeastern states and Uttar Pradesh had the highest median under-vaccination. Despite India's high aggregate vaccine coverage, the distribution of small-area (cluster) mean prevalence highlighted pockets of low coverage in most states, suggesting ongoing vulnerability to measles and polio.

Interpretation: Achieving India's vaccination goals requires a strategic shift towards identification and targeting of low-immunity clusters at the sub-district level.

Funding: Canadian Institutes of Health Research.

Keywords: Child health; Developing countries; Equity; Health inequalities; Immunization programs; India/epidemiology; Vaccination coverage/∗statistics & numerical data; Vaccination/∗statistics & numerical data.